The Slow Return to "Normal"

I'm an HIV-positive New York City male in my mid-forties. I'm a tough guy, but since the World Trade Center attack I get uptight about leaving my apartment, walking down the street, taking the subway, going into skyscrapers or getting into elevators. Doing just about anything, I start to think about being hit by a terrorist bomb. Let's face it, I'm scared, and being HIV positive, I'm double-scared. I'm not employed right now so I don't have to leave my apartment, but I feel sleepy all the time and depressed, and at some point I do have to get a job. This terrorist attack is still really on my mind and I'm wondering if I need to see a psychologist. What can I do? This has really gotten to me...

A Response to This Case Study

The terrorist attacks directed toward our nation clearly affected the emotional stability of many individuals on many different levels. As a nation we do not know what to expect in the coming days, weeks or months, and this uncertainty raises and heightens our level of anxiety. Psychological research has consistently pointed out that people do not do well emotionally when they don't know what to expect next in life. In this situation, with a possible war and additional threats of attack, our future sense of security is uncertain and this can create problematic behaviors connected to our own emotional uncertainty.

To help lessen anxiety and restore a sense of control in their lives, people may seek quick solutions, such as saying that "all foreigners must leave the U.S.A." or look to place blame, such as by persecuting "foreign-looking" people. Such reactions may help people to gain a feeling of power over what appears to be an uncontrollable event, but those who allow their fears and confusion to rule their movements can also face depression and isolation.

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After any traumatic event, the emotional brain goes into shock and attempts to adjust to its former equilibrium. Your brain needs the time to process the event and to come to terms with what had just taken place. How one goes about the process of recovery differs from person to person; there is no one "right" way to deal with denial, shock, confusion and grief. When the emotional brain is ready to process the event and the comprehension sinks in, the brain will run its course and the person will let out their feelings verbally or in a chosen creative outlet. The point here is when people are ready to verbalize their feelings they will; they should not feel pushed or forced into talking by other concerned individuals.

I believe people for the most part are their own experts when it comes to their personal emotional needs. If you feel you need a mental health professional to discuss your issues and concerns with, then I would encourage you to do so. (See the article in this issue for signs and symptoms that you may need to seek professional mental health care.) However, in an attempt to help you come to your own conclusion let's examine some additional points. In addition, I will attempt to clarify what post-traumatic stress disorder (PTSD) is and what you can look for as common symptoms for this diagnosis.

From your written statement you give the impression of having a prevailing expectant anxiety of another attack. With any traumatic event there is a sense of anxiety and a possible over-preoccupation with expectant fears that can envelop the person and affect him or her negatively. Naturally, these thoughts could cause great distress and concern and may cause you to have a great deal of stress in your daily structure. Your fears, coupled with a lost sense of power in your life, have affected your most routine movements and you sound as if you have retreated from the world. Sleeping, eating, and the general basic life structure (employment, relationships, sense of control and freedom over one's pursuits) of individuals varies, but for each of us this is this basic ground work that should always be re-examined following a traumatic event.

When basic areas of life lose their equilibrium; depression can take over and lead to a loss of appetite, irritation, and disinterest in one's usual pursuits and general fatigue. These are common symptoms of anxiety that can precede PTSD. However, they can also be natural signs that you are coming to terms with what has just happened. It really all depends on the severity of your symptoms. To regain your emotional balance, be sure to eat correctly and often, get your sleep, and prioritize having fun. Humor and laughter can boost your immune system and help to lessen your emotional pain. Hopefully in time you will rebuild your emotional strength.

You can regain your own power and have a sense of control over your fears regardless of the future events. Right now, your fears are ruling you and controlling your movements. You need to start to take the small steps, which are actually big steps to regain your control over the fears that are stopping you from functioning on your most basic everyday level. No doubt you will have anxiety walking, taking the subway, the ferry or going inside a skyscraper at first or for the first few times, or maybe for a number of months, but you must push yourself to take those first steps. It is normal and natural for another attack to be on everyone's mind -- you are not alone and you have good reason to be fearful. However, life must also continue, so keep your life structured and challenge yourself to take steps that will take you outside in the world that surrounds you.

Thoughts that are dependant on specific cues (for example: subway = terrorist attack, skyscraper = terrorist attack, elevator = terrorist attack) produce these fears based on a traumatic past experience. Then these thoughts produce a pervasive fear that keeps you in isolation. The pay-off and the positive reinforcement for overcoming fears are your continued interaction with friends and with the rest of the world outside your apartment, but you need to take the courageous steps to rejoin the living world.

Ask yourself what you are missing in your life by staying inside. Are you missing a sense of belonging or the love from people you know or who care about you? The phone can keep you connected with them but face-to-face sessions are more inmate and emotionally rewarding. You can watch television all day, but social human stimulation is where you also receive attention, praise, recognition, and pleasurable interactions. Once you have found a job, financial gains through employment in addition to the structure and a sense of belonging with co-workers will continue to help you adjust during this period. Now you must start with taking the basic first steps of rejoining the world and living with your fears.

In time, you will have power once again over your fears, just as you have learned to adjust to your HIV status. But one must rejoin the world by doing it daily and with purpose, the number one concern is your health and living as stress-free a life as humanly possible. Look at this as another form of exercise that you must do every day for your health. Like anything else, it will take time and a strong structured routine to re-learn what you had once taken for granted as a way of life. Here are some additional suggestions and points.

Contributing to the recovery effort can help to lower your stress. This is a very pro-active, healthy way to contribute to the nation's recovery and the larger picture. In general, volunteering is an excellent component to have in your weekly structure. You need to get out of your apartment to help people who need you. You are also directing your own stress and concerns into a healthy outlet. Take a part of your week, anywhere from one to three hours, to volunteer your time. Have you considered volunteering your time for any HIV-related cause? In this way, you can place your energies into a good outlet in an area of concern to you.

Keep your life structured. This is easier said then done, but you can do it. Your life should be full and accounted for. There should be employment that is structured with work expectations that are clear and rewarding. I would encourage you now to seek out a job. Start your interview process and get into the structure of getting up at an early time, shower, and shave and leave your apartment for breakfast, as if you are already going off to work. Spend at least two to three hours actively searching for that right job. To fight off the "blues," a consistent daily structure to follow is always recommended.

You should also have a part of the day that is devoted toward socialization and relaxation. Eat, sleep and do things that bring you fun and pleasure, which will hopefully lower your stress level. "Escapism" is not a bad word. Read a novel, watch a movie, and become involved in activities that remove you for a time from your everyday stresses and concerns. You need to feel you have choice and freedom in your life. If you feel trapped then change your situation.

Be willing to be open and to ask for professional help for yourself and others. Many emotional cures lie in the process of verbal therapy. Talk releases tension, and gives people a sense of themselves and others. This can in many cases replace the emotional isolation they feel. Talk about your fears with friends who may have similar issues and together you maybe able to develop some strategies for meeting your fears head on, together or separately. If you continue to have these overwhelming feeling, and this continues for over a month and you have lost the ability to function, then you should strongly consider seeking professional mental health counseling.

Motivate your self to get out. Begin by taking task-directed trips to places that you are needed to attend. Activities such as possible job interviews, trips to the supermarket, and meeting friends for social interactions are all possible motivators to actively reward you once you reach your task-directed goal.

The essential features of post-traumatic stress disorder (PTSD) are the consequences of an emotionally damaging event to which someone has been exposed to. This traumatic event as in the World Trade Center attack then can result in fear, guilt, personal responsibility or a sense of helplessness in preventing the tragedy. PTSD can involve direct personal experience or observation of the situation of threatened death or serious injury, or threats made to one's physical integrity. Generally speaking, the worse the trauma, the greater the possibility of developing PTSD.

It is important to remember that common reactions to the World Trade Center trauma do not indicate PTSD, which manifests after about four weeks when the stresses we have just addressed have not lessened and the individual has lost the ability to function productively. These individuals are ruled by their fears in such an overpowering way that their fears now rule their everyday movements. They have limited freedom of thought and limited choice in their movements, and can react negatively to cue-dependent triggers. The individual's fear and sense of helplessness are re-experienced, usually in recollections of the traumatic event, including intrusive thoughts, recurring dreams and flash-backs in which the patient has a sense of reliving the event. Patients characteristically attempt to avoid whatever might trigger their emotions and this gravely impacts their life on its most basic level.

Your concerns are real, and coupled with your HIV status, your stresses for your own emotional health must be kept to minimum. I urge you to address your feeling with others like yourself and rejoin the world of living people that surrounds you. What has happened to our nation is a shock and has affected many. It is not unusual for people briefly to develop any or all of these symptoms after experiencing this horrible traumatic event. However, in time most people learn to live with their fears and return to normal functioning. Good luck!

"Psychologically Speaking" columnist J. Buzz von Ornsteiner, Ph.D. is a New York State-licensed psychologist. He currently works at a New York State correctional facility as a psychotherapist, behavioral consultant, and educator.

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